Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 General principles

1.1.1 Be aware that multimorbidity refers to the presence of 2 or more long-term health conditions, which can include:

defined physical and mental health conditions such as diabetes or schizophrenia

ongoing conditions such as learning disability

symptom complexes such as frailty or chronic pain

sensory impairment such as sight or hearing loss

alcohol and substance misuse.

1.1.2 Be aware that the management of risk factors for future disease can be a major treatment burden for people with multimorbidity and should be carefully considered when optimising care.

1.1.3 Be aware that the evidence for recommendations in NICE guidance on single health conditions is regularly drawn from people without multimorbidity and taking fewer prescribed regular medicines.

1.1.4 Think carefully about the risks and benefits, for people with multimorbidity, of individual treatments recommended in guidance for single health conditions. Discuss this with the patient alongside their preferences for care and treatment.

1.2 Taking account of multimorbidity in tailoring the approach to care

1.3.2 Consider using a validated tool such as eFI, PEONY or QAdmissions, if available in primary care electronic health records, to identify adults with multimorbidity who are at risk of adverse events such as unplanned hospital admission or admission to care homes.

1.3.3 Consider using primary care electronic health records to identify markers of increased treatment burden such as number of regular medicines a person is prescribed.

1.3.4 Use an approach to care that takes account of multimorbidity for adults of any age who are prescribed 15 or more regular medicines, because they are likely to be at higher risk of adverse events and drug interactions.

1.3.5 Consider an approach to care that takes account of multimorbidity for adults of any age who:

are prescribed 10 to 14 regular medicines

are prescribed fewer than 10 regular medicines but are at particular risk of adverse events.

1.4 How to assess frailty

1.4.1 Consider assessing frailty in people with multimorbidity.

1.4.2 Be cautious about assessing frailty in a person who is acutely unwell.

1.4.3 Do not use a physical performance tool to assess frailty in a person who is acutely unwell.

Primary care and community care settings

1.4.4 When assessing frailty in primary and community care settings, consider using 1 of the following:

an informal assessment of gait speed (for example, time taken to answer the door, time taken to walk from the waiting room)

self-reported health status (that is, 'how would you rate your health status on a scale from 0 to 10?', with scores of 6 or less indicating frailty)

a formal assessment of gait speed, with more than 5 seconds to walk 4 metres indicating frailty

the PRISMA-7 questionnaire, with scores of 3 and above indicating frailty.

Hospital outpatient settings

1.4.5 When assessing frailty in hospital outpatient settings, consider using 1 of the following:

self-reported health status (that is, 'how would you rate your health status on a scale from 0 to 10?', with scores of 6 or less indicating frailty)

the 'Timed Up and Go' test, with times of more than 12 seconds indicating frailty

a formal assessment of gait speed, with more than 5 seconds to walk 4 metres indicating frailty

the PRISMA‑7 questionnaire, with scores of 3 and above indicating frailty

self-reported physical activity, with frailty indicated by scores of 56 or less for men and 59 or less for women using the Physical Activity Scale for the Elderly.

1.5 Principles of an approach to care that takes account of multimorbidity

1.5.1 When offering an approach to care that takes account of multimorbidity, focus on:

how the person's health conditions and their treatments interact and how this affects quality of life

how the individualised management plan and the responsibility for coordination of care is communicated to all professionals and services involved

timing of follow-up and how to access urgent care.

1.6 Delivering an approach to care that takes account of multimorbidity

1.6.1 Follow the recommendations in the NICE guideline on patient experience in adult NHS services, which provides guidance on knowing the patient as an individual, tailoring healthcare services for each patient, continuity of care and relationships, and enabling patients to actively participate in their care.

Discussing the purpose of an approach to care that takes account of multimorbidity

1.6.2 Discuss with the person the purpose of the approach to care, that is, to improve quality of life. This might include reducing treatment burden and optimising care and support by identifying:

non-pharmacological treatments as possible alternatives to some medicines

alternative arrangements for follow-up to coordinate or optimise the number of appointments.

Establishing disease and treatment burden

1.6.3 Establish disease burden by talking to people about how their health problems affect their day-to-day life. Include a discussion of:

mental health

how disease burden affects their wellbeing

how their health problems interact and how this affects quality of life.

1.6.4 Establish treatment burden by talking to people about how treatments for their health problems affect their day-to-day life. Include in the discussion:

the number and type of healthcare appointments a person has and where these take place

the number and type of medicines a person is taking and how often

any harms from medicines

non-pharmacological treatments such as diets, exercise programmes and psychological treatments

any effects of treatment on their mental health or wellbeing.

1.6.5 Be alert to the possibility of:

depression and anxiety (consider identifying, assessing and managing these conditions in line with the NICE guideline on common mental health problems)

chronic pain and the need to assess this and the adequacy of pain management.

Establishing patient goals, values and priorities

1.6.6 Clarify with the patient whether and how they would like their partner, family members and/or carers to be involved in key decisions about the management of their conditions. Review this regularly. If the patient agrees, share information with their partner, family members and/or carers. [This recommendation is adapted from the NICE guideline on patient experience in adult NHS services.]

1.6.7 Encourage people with multimorbidity to clarify what is important to them, including their personal goals, values and priorities. These may include:

maintaining their independence

undertaking paid or voluntary work, taking part in social activities and playing an active part in family life

preventing specific adverse outcomes (for example, stroke)

reducing harms from medicines

reducing treatment burden

lengthening life.

1.6.8 Explore the person's attitudes to their treatments and the potential benefits and harms of those treatments. Follow the recommendations on patient involvement in decisions about medicines and understanding the patient's knowledge, beliefs and concerns about medicines in the NICE guideline on medicines adherence.

1.6.10 Consider using a screening tool (for example, the STOPP/START tool in older people) to identify medicine-related safety concerns and medicines the person might benefit from but is not currently taking. [This recommendation is adapted from the NICE guideline on medicines optimisation.]

1.6.11 When optimising treatment, think about any medicines or non-pharmacological treatments that might be started as well as those that might be stopped.

1.6.12 Ask the person if treatments intended to relieve symptoms are providing benefits or causing harms. If the person is unsure of benefit or is experiencing harms from a treatment:

discuss reducing or stopping the treatment

plan a review to monitor effects of any changes made and decide whether any further changes to treatments are needed (including restarting a treatment).

1.6.13 Take into account the possibility of lower overall benefit of continuing treatments that aim to offer prognostic benefit, particularly in people with limited life expectancy or frailty.

1.6.14 Discuss with people who have multimorbidity and limited life expectancy or frailty whether they wish to continue treatments recommended in guidance on single health conditions which may offer them limited overall benefit.

1.6.15 Discuss any changes to treatments that aim to offer prognostic benefit with the person, taking into account:

their views on the likely benefits and harms from individual treatments

what is important to them in terms of personal goals, values and priorities (see recommendation 1.6.7).

1.6.16 Tell a person who has been taking bisphosphonate for osteoporosis for at least 3 years that there is no consistent evidence of:

further benefit from continuing bisphosphonate for another 3 years

harms from stopping bisphosphonate after 3 years of treatment.

Discuss stopping bisphosphonate after 3 years and include patient choice, fracture risk and life expectancy in the discussion.

Agreeing the individualised management plan

1.6.17 After a discussion of disease and treatment burden and the person's, personal goals, values and priorities, develop and agree an individualised management plan with the person. Agree what will be recorded and what actions will be taken. These could include:

assigning responsibility for coordination of care and ensuring this is communicated to other healthcare professionals and services

other areas the person considers important to them

arranging a follow-up and review of decisions made.

Share copies of the management plan in an accessible format with the person and (with the person's permission) other people involved in care (including healthcare professionals, a partner, family members and/or carers).

Terms used in this guideline

Multimorbidity

Multimorbidity refers to the presence of 2 or more long-term health conditions, which can include:

defined physical and mental health conditions such as diabetes or schizophrenia

ongoing conditions such as learning disability

symptom complexes such as frailty or chronic pain

sensory impairment such as sight or hearing loss

alcohol and substance misuse.

The management of risk factors for future disease can be a major treatment burden for people with multimorbidity and should be carefully considered when optimising care.

This guideline covers the optimisation of care for:

adults with 2 or more long-term physical health conditions

adults with 1 or more mental health condition and at least 1 physical health condition.

An approach to care that takes account of multimorbidity

An approach to care that takes account of multimorbidity involves personalised assessment and the development of an individualised management plan. The aim is to improve quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care. The approach takes account of a person's individual needs, preferences for treatments, health priorities and lifestyle. It aims to improve coordination of care across services, particularly if this has become fragmented.

Individualised management plan

An individualised management plan is a management plan covering clinical aspects of a person's care, such as the medicines they are taking and the services they are attending. It includes information about which areas of care are most important to the person and whether treatments have been stopped to reduce treatment burden.

Medicines

Medicines includes topical treatments such as ointments, inhalers, creams and drops, as well as medicines taken by mouth or injection.

Comprehensive assessment of older people with complex needs

A comprehensive geriatric assessment is an interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old. The aim is to develop a coordinated, integrated plan for treatment and long-term support.